WELCOME TO PROLIANCE - SURGICAL SPECIALIST AT OVERLAKE!

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1 Adel El-Ghazzawy, MD, FACS Helen Kim, MD, FACS Oliver Biggers, MD, FACS Geoffrey Chow, MD Sung Cho, MD, FACS th Ave. NE, Suite 535 Bellevue, WA Phone: Fax: WELCOME TO PROLIANCE - SURGICAL SPECIALIST AT OVERLAKE! Thank you for choosing our office to meet your specialized medical needs. The first visit with one of our surgeons is usually a consultation to review the medical issues and mutually plan for a course of action. This may include additional testing and evaluation with other specialists and your primary care provider to be sure that all medical issues are considered and addressed. What to bring: Insurance Card(s) Photo ID Check, cash, or credit card for co-payments, deductibles and co-insurance due for the visit Any forms that have been sent, completed for the appointment Please arrive 15 minutes early, as we will need to complete the preparation of your medical forms and records as necessary. We are located in the Overlake Medical Pavilion at Overlake Hospital. Parking is available in the Overlake Medical Pavilion garage for a nominal fee. Directions from North of Bellevue: Take I-405 Southbound. Exit at NE 8 th street (exit number 13B, there are signs for the hospital). Follow the loop, staying to the right. Once on 8 th street, get into the far left lane. Take a left onto 116 th Ave. NE. Turn Left onto NE 10 th St. Take a right into the hospital campus. The Overlake Medical Pavilion garage can be accessed from Felix Terry Swistak Dr NE, or 116 th Ave NE. Directions for South of Bellevue: Take I-405 Northbound. Exit at NE 4 th Street (exit number 13A). At the traffic light, turn left onto 116 th Ave. NE. Turn Left onto NE 10th St. Take a right into the hospital campus. The Overlake Medical Pavilion garage can be accessed from Felix Terry Swistak Dr NE, or 116 th Ave NE. If you have any questions, please contact us between 8-5:00 p.m. We look forward to seeing you soon th Ave. NE, Ste 535, Bellevue WA fax

2 PATIENT REGISTRATION Patient Name MRN: SSN DOB Age Sex Mailing Address Marital Status Contact Information Home Phone: Parent/Spouse/Partner Name _ Consent to leave detailed message: Answering Machine: Y N Day Phone: Work Phone: Person(s) at home: Y N Alternate Phone: Cell Phone: Place of Employment: Y N Race: White Native Hawaiian/Pacific Islander American Indian/Alaska Native Black Asian Prefer not to Disclose Unknown Other Ethnicity: Hispanic/Latino Not Hispanic or Latino Prefer not to Disclose_ Unknown_ Language. Emergency Contact: Name Number Relationship., -- Primary Care Physician Preferred Pharmacy Referring Provider Pharmacy Location You may disclose the following health care information in my medical record: _ALL Health care information _ Health care information related ONLY to the following conditions: Regarding service I have received, I give permission for any doctor, physician assistant or staff member of Proliance - Surgical Specialists at Overlake to speak to and/or release information to the following: Name: Relationship: Name: Relationship: I authorize the staff at Proliance - Surgical Specialists at Overlake to leave a detailed message with the following: _ My Spouse _ Other Family Member I hereby authorize my insurance benefits be paid directly to the physician. I am financially responsible for any balance due. I also authorize the doctor or insurance company to release information required for this claim. I consent to the release of medical information from or to other doctors and healthcare institutions as is necessary to my care and treatment. This authorization is valid for 12 months from the date it is signed. Signature of Patient/Parent/Power of Attorney Date

3 PATIENT HEALTH HISTORY FORM Ht: Wt: PLEASE LIST CURRENT MEDICATIONS: Mgs/Strength & How Many Times a Day ARE YOU TAKING ASPRIN? YES NO PLEASE LIST CURRENT ALLERGIES: OR REACTIONS YOU MAY HAVE: WHAT IS YOUR PAST SURGICAL HISTORY: Year: Operation: PLEASE LIST CURRENT MEDICAL HISTORY: DIABETIC: YES NO TYPE I or II MRSA: YES NO CPAP: YES NO PACEMAKER: YES NO Patient Name: DOB:

4 PATIENT HEALTH HISTORY FORM (continued) Have you ever been seen by a Cardiologist? (Heart doctor) Have you or any relatives had a problem with Anesthesia? Have you ever had an EKG? YES NO Name of Cardiologist: YES NO YES NO When/Where: Can you climb 2 flights of stairs without shortness of breath YES NO With or Without assistance PERSONAL HEALTH HISTORY: HIGH BLOOD PRESSURE GLASSES/DENTURES CORONARY ARTERY DISEASE PLEASE CIRCLE IF YOU HAVE ANY OF THE HEALTH CONDITIONS BELOW: PE - Pulmonary Embolism HIGH CHOLESTEROL ARTHRITIS/GOUT SOCIAL HISTORY AND HEALTH HABITS: Relationship Status: Single Partnered Married Separated Divorced Widowed Smoking No Type: Packs a Day: Quit (Year): Alcohol No Drinks a Day: Drinks a Week: Drinks a Month: Quit(Year): Drugs Type: FAMILY HEALTH HISTORY: Maternal Mother Father Grandfather Grandmother Aunt/Uncle Brother Sister Son Daughter Paternal Mother Father Grandfather Grandmother Aunt/Uncle Brother Sister Son Daughter Patient Name: DOB:

5 REVIEW OF SYSTEMS Check Box and Give Details Constitutional Symptoms: Fertility/Reproduction: Weight Loss/Gain: lbs. Pregnancies: Fevers Miscarriages: Night Sweats Menopause/ Post-Menopausal Eyes: Tubal Ligation Glaucoma Vasectomy Macular Degeneration Muscles/Joints: Head and Neck: Arthritis Sinus Infection Joint Replacement Swollen Glands Back Pain Dentures/Partial Plate Skin: Radiation to Face or Neck Rashes Skin Cancer MRSA (Active) Heart: History of MRSA Chest Pain/Angina Pectoris Heart Attack/Myocardial Infarction Breasts: Irregular Heartbeat Breast Pain Shortness of Breath, Lying Down Breast Mass Swelling, in Feet or Legs Nipple Discharge Stents in Heart Pacemaker Neurologic: Lungs: Loss of Memory Asthma/Wheezing Seizures COPD/Emphysema Migraines Respiratory Infections Depression Sleep Apnea Bipolar Disorder Anxiety Gastrointestinal: Stroke, TIA/CVA (Mini/Major) Heartburn/GERD Endocrine: Ulcers Thyroid Problems Frequent Diarrhea Diabetes Constipation Blood in Stool Blood Problems: Hemorrhoids Anemia Hepatitis Bleeding Problems Clotting Problems Genitourinary: Transfusions Difficulty Voiding Frequent Urination Allergies: Kidney Stones Latex Painful Urination Iodine/Contrast Patient Name: DOB:

6 Adel El-Ghazzawy, MD, FACS Helen Kim, MD, FACS Oliver Biggers, MD, FACS Geoffrey Chow, MD Sung Cho, MD, FACS th Ave. NE, Suite 535, Bellevue, WA Phone: Fax: Authorization to Leave Personal Health Information, Alternate Means Patient Name: DOB: Mailing Address: Please fill in all that apply. 1. May leave detailed message on voic at home: 2. May leave detailed message on voic at work: 3. May leave information with spouse (name) 4. May leave information with other family member (name): 5. May leave information at different location (specify): 6. May leave information at address: Note: With my signature, I acknowledge and understand that this information will be kept in my medical record and the above parameters will be abided by until revoked by me in writing. It is my responsibility to notify my health care provider(s) should I change one or more of the contacts listed above th Ave. NE, Ste 535, Bellevue WA fax

7 Adel El-Ghazzawy, MD, FACS Helen Kim, MD, FACS Oliver Biggers, MD, FACS Geoffrey Chow, MD Sung Cho, MD, FACS th Ave. NE, Suite 535, Bellevue, WA Phone: Fax: NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT We keep a record to the health care services we provide you. You may ask to see and copy that record. You may also ask to correct said record. We will not disclose your record to others unless you direct us to do so, or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting the administrator of the location at which you have been treated. Please call the main office number and ask for the administrator. Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed and how you can access your information. You may obtain a copy of our Notice of Privacy Practices at any point by requesting one from the staff. By my signature below, I acknowledge receipt of the Notice of Privacy Practices. Signature of patient OR patient s authorized representative. Date Signed Relationship or status if signed by anyone other than patient (for example: parent, legal guardian, personal representative, etc.) th Ave. NE, Ste 535, Bellevue WA fax

8 Patient Financial Responsibilities Proliance - Surgical Specialists at Overlake, a division of Proliance Surgeons is committed to providing you with the highest quality medical care. Because patients are ultimately responsible for the charges associated with their care, even when insurance is in place, you may find the following information helpful. We realize you have choices for your medical care and appreciate your choosing Proliance - Surgical Specialists at Overlake. Patient Responsibilities You can help ensure an efficient experience by assisting with the following: Providing us with your picture identification, insurance card and Social Security number to enable us to submit your claims timely and accurately Knowing your insurance benefits and limitations Ensuring there is an authorization for our providers to treat you if it is required by your insurance, including obtaining a referral Providing us with copies of any pertinent medical records, including tests (MRI/CT/Arthrogram) and x-rays Paying your estimated portion of the charges at the time of service Paying any additional amount owed when due Completing required incident/accident forms within 30 days of date of service Maintaining a current account with Proliance Surgeons at all times Providing us with at least 24 hours advance notice should you need to cancel or reschedule an appointment Please note that co-payments, co-insurance and deductibles are a contractual agreement between you and your insurance carrier. We cannot change or negotiate these amounts. Insured Patients We will bill your primary and secondary insurance carrier in a timely manner. If you are disputing payment with your insurance carrier or have a balance over $ with us, you must notify our business office and make payment arrangements. Co-Pays/Deductibles/Co-Insurance Please be prepared to pay for your portion of the charges on the date of service. Surgery If surgery is indicated, a pre-payment of both physician and facility fees is required for all elective, non-emergent procedures prior to the surgery being performed. Your out-of-pocket cost is estimated based on your benefits and our fees. Anesthesia and other providers are separate fees. Non-Participating Insurance If we do not participate in the insurance you have, we will file a claim as a courtesy. All unpaid claims will become your responsibility 45 days following filing and be immediately due and payable. Uninsured Patients Office Visits A $ deposit is required prior to the appointment. If visits and services are paid in full at the time of service, we offer a 20% discount (see exclusions below). Office visits may include x-rays, casting and materials at an additional charge. Charges are not finalized until chart notes are complete. Surgery For uninsured patients having surgery, we offer a 20% discount when charges are paid before or on the day of service (see exclusions below). Eff. 11/14/13 kw

9 Exclusions The discounts referenced above do not apply in cases of motor vehicle accidents, third party insurance claims or in other cases when the patient may be reimbursed in full. Private pay patients who receive retroactive Medicaid coverage need to immediately notify our business office. Motor Vehicle Accidents (MVA) Insured and Third Party Patients We do not extend discounts for MVA-insured accidents, third party insurance claims or in other cases when patients may be reimbursed in full. We will bill the MVA insurance carrier one time. The bill becomes your responsibility if not paid by the carrier in 30 days. We regret that we are not in a position to confer with attorneys or defer payment obligations while a case settles. If your personal injury protection benefit on your MVA policy is exhausted, we will bill your private insurance at your request provided we are furnished the necessary information at the date of service. Workers Compensation If your visit is work-related, we will need the case number and carrier name prior to your visit in order to bill the workers compensation insurance carrier. If your workers compensation claim is not yet accepted and you have no other insurance, we require a $ deposit that will be refunded after the claim has been opened. Other Charges No Show Please provide us with at least 24 hours advance notice if you need to cancel or reschedule an appointment. We may charge a fee for missed appointments. Please provide us with at least 48 hours advance notice if you need to cancel or reschedule an appointment and an interpreter has been scheduled. Otherwise, you may be charged for the interpreter. Forms There may be a charge associated with our completion of some forms. We require payment of the charge before returning the completed form to you. A signed Release of Information may also be necessary. Please allow five business days for us to complete forms. Payment Payment Options We accept cash, checks, major credit/debit cards and money orders for payment (no post-dated or third party checks). We charge a $40.00 NSF fee for any returned checks. Delinquent Accounts We charge a $10.25 monthly account management fee on balances over 45 days old. We may assign an account to collections if balances are unpaid after 60 days. Patients assigned to collections may be denied additional service. Alternative Payment Arrangements If you are unable to pay your balance when due, please contact our business office to make alternative arrangements. Any patient with a past due amount may be denied additional service until the amount is paid or the patient is complying with an alternative payment arrangement. Bankruptcy/Prior Bad Debt Patients who have previously filed for bankruptcy or never satisfied their payment obligations for prior episodes of care with Surgical Specialist at Overlake or other Proliance Surgeons care centers may be required to pay for their portion of new charges at the time of service. Signature of Patient/Guardian Printed Name of Patient Date Office Hours: 8:00am 5:00pm, Monday thru Friday Office Phone: (425) PSSO accepts Visa, MasterCard, American Express, and Discover Credit Cards Eff. 11/14/13 kw

Patient Registration. Mailing Address: Alternate Phone#: Pharmacy Address: Insurance Information. Primary Insurance Name: Name of Insured/Subscriber:

Patient Registration. Mailing Address: Alternate Phone#: Pharmacy Address: Insurance Information. Primary Insurance Name: Name of Insured/Subscriber: Patient Registration Patient Name: Social Security #: DOB: Sex M F Marital Status: Mailing Address: Primary Phone#: Alternate Phone#: Primary Care Physician: Preferred Pharmacy: Home Phone#: Email: Referring